CASE STUDIES

APRIL 01, 2005

Lauren S. Schlesselman, PharmD

CASE 1: NA, a 37-year-old female, comes to the clinic for a follow-
up. Currently, she has no complaints.

NA was diagnosed with Graves'disease 2 months earlier. At
that time, she was experiencing symptoms of hyperthyroidism,
including tachycardia. She was started on propylthiouracil 200 mg
every 6 hours and propranolol 20 mg 4 times daily.

On physical examination, NA is a well-developed, thin female in
no acute distress. Her vital signs are recorded as follows: blood
pressure 140/90 mm Hg, heart rate 80 beats/min, respiratory rate
16 breaths/min, temperature 37̊C, and weight 58 kg. She has a
small symmetric goiter that is much smaller than it was 2 months
ago. She also has pruritic pretibial myxedema. The remainder of
her examination, including her eye exam, is within normal limits. All
laboratory results are within normal limits, including thyroid panel.

When the practitioner informs NA that her Graves'disease is
currently under control, NA is thrilled. She does not enjoy taking so
many tablets daily. She notifies the practitioner that she is going to
throw "all those bottles"in the trash as soon as she gets home.
The practitioner breaks the bad news to NA that she cannot
abruptly discontinue her therapy. NA is extremely disappointed.

Can the practitioner discontinue or taper the propylthiouracil
and propranolol?

CASE 2: ZV, a 15-year-old girl, is brought by her mother to the
pediatric clinic. ZV is slightly jaundiced. She denies any abdominal
pain, alcohol use, or abdominal trauma. She denies taking
any medications or using illicit drugs. Her mother insists there is
no history of liver disease. Neither one can identify any exposure
to toxins.

ZV's vital signs are within normal limits. Her laboratory work
shows an elevated bilirubin, gamma-glutamyl transpeptidase
(GGTP), and alkaline phosphatase (ALP), but relatively normal
aminotransferases. The pediatrician orders an ultrasound of the
liver and biliary system. The ultrasound results are also normal
with no evidence of biliary dilation, leading the pediatrician to suspect
intrahepatic cholestasis, rather than extrahepatic.

Despite a thorough history and physical examination, the pediatrician
cannot find a cause for ZV's jaundice. After discussion with
ZV's mother, he schedules an appointment for ZV with a pediatric
hepatologist. He explains that the hepatologist will perform a liver
biopsy to determine the cause.

When a terrified ZV returns home from the pediatric clinic, she
telephones her sister. Her sister is a pharmacist at the local hospital.
Her sister begins questioning ZV for possible clues to identify
the cause of the jaundice. Finally, ZV confides to her sister that she
is taking birth control tablets that she received from the local family
planning clinic. She does not want to tell her mother because
she knows her mother will be upset. She asks her sister if she
should reveal this information to their mother.

Could the birth control tablets be the cause of ZV's intrahepatic
cholestasis (and does she need to inform her mother)?